Editorial Comment for Salami et al.

The authors show that complex hilar lesions can be resected using minimally invasive surgical techniques without clamping the renal vessels. Everyone agrees that short warm ischemic times are better than long ischemic times for preserving postoperative renal function. It remains to be proved that a case with no renal ischemia leads to improved postoperative renal function over a case performed with a short ischemic time.

Case selection is crucial for success. Exophytic masses should be chosen initially. Dissection of the hilar vessels is prudent to allow for emergent vascular control in cases where bleeding occurs during off-clamp resection.

At Washington University, we start the resection at the medial aspect of the mass. We dissect the mass away from the large vessels. Usually it is not difficult to develop this plane. In most cases, vessels feeding the mass are small and can be cauterized and divided. Once the mass has been mobilized away from the hilar vessels, the renal parenchyma on the cephalad, caudal, and lateral aspects can usually be divided with very little bleeding because most of the blood supply to the mass has been controlled in the medial dissection. This technique evolved as we sought to minimize warm ischemic times by doing as much of the dissection as possible before clamping the vessels. Surprisingly, we found most masses could be resected without clamping the renal artery.

Further study is needed to determine whether off-clamp minimally invasive partial nephrectomy improves patient outcomes. The authors have shown in this small series that excellent renal functional and oncologic outcomes can be achieved when managing complex renal masses without ischemia to the kidney using minimally invasive surgical techniques.